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Medicare Advantage HMO vs. Original Medicare: Which Should You Choose?


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Are you thinking about Medicare Advantage HMO (Health Maintenance Organization) plans, and wondering how they compare with Original Medicare? We’ll take you through the basic benefits of Original Medicare (Part A and Part B) vs. Medicare Advantage HMO plans.

What does Original Medicare (Part A and Part B) give you?

Before we get to Medicare Advantage HMO plans, let’s talk about Original Medicare. This is the government fee-for-service program for those who qualify by age or disability. Original Medicare includes Part A and Part B.

Medicare Part A (hospital insurance) typically covers:

  • Inpatient hospital stays
  • Inpatient mental health hospital stays
  • Hospice care
  • Skilled nursing care
  • Limited home health-care services

A deductible and coinsurance and/or copayments apply to most services. Most people don’t pay a monthly premium for Part A, but if you haven’t worked at least 10 years (40 quarters) while paying taxes, you might pay a premium for Part A.

Medicare Part B (medical insurance) may cover medical services and items such as:

  • Doctor office visits
  • Durable medical equipment, such as walkers
  • Emergency transportation by ambulance
  • Preventive services such as certain tests and screenings
  • Cardiac rehabilitation
  • Laboratory services
  • Flu shots
  • Chemotherapy
  • Physical or occupational therapy

This is by no means a complete list. Part B may cover a wide range of services. You’ll generally pay 20% of the Medicare-approved amount for each item or service. A deductible may apply. Most people pay a monthly Part B premium.

For both Medicare Part A and Part B to cover your services and items, providers must accept Medicare assignment.

What does a Medicare Advantage HMO plan give you?

How about just about everything Original Medicare gives you – and then some? A Medicare Advantage HMO plan delivers all your Medicare Part A and Part B benefits, except hospice care – but that’s still covered for you directly under Part A, instead of through the plan.

Medicare Advantage plans are offered by private, Medicare-approved insurance companies. They contract with Medicare to deliver your Part A and Part B benefits as described above. Some plans, such as Medicare Advantage HMO plans, have provider networks that help keep costs down. You typically need to stay within the provider network when you get medical care.

Most Medicare Advantage HMO plans also include prescription drug benefits. Original Medicare includes only limited prescription drug coverage. Part A may cover medications given to you as a hospital inpatient, and Part B may cover prescription drugs administered to you as an outpatient – generally those you wouldn’t take on your own (for example, intravenously administered medications). Original Medicare doesn’t cover most medications you’d take at home, while a Medicare Advantage HMO plan might.

You must continue paying your Medicare Part B premium, along with any premium the plan may charge.

Medicare Advantage HMO vs Original Medicare: what’s the difference?

If both types of Medicare coverage provide Part A and Part B benefits, what sets them apart from one another? Here’s a table that lists their features clearly.

Medicare Advantage HMO Original Medicare
Includes prescription drug coverage? Usually No (except in limited situations)
Lets you see any doctor who accepts Medicare assignment? Generally must stay within provider network Yes
Protects you with an annual maximum out-of-pocket spending limit? Yes No
Offers extra benefits beyond Part A & Part B?

 

Besides prescription drug coverage, some plans offer routine vision or dental services, for example. No

We hope this article has clarified the ways that Original Medicare and Medicare Advantage HMOs are alike, and how they differ. If you’d like to explore Medicare Advantage plan choices in your area, just enter your zip code in the box on this page.

The provider network may change at any time. You will receive notice when necessary.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

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